Impact of 2003 state regulation on raw oyster-associated Vibrio vulnificus illnesses and deaths, California, USA

US vibriosis rates have increased since 1996, and many Vibrio vulnificus infections are fatal. In April 2003, California implemented a regulation restricting the sale of raw oysters harvested from the Gulf of Mexico during April 1-October 31, unless they were processed to reduce V. vulnificus to nondetectable levels. We analyzed California cases of V. vulnificus infection before and after the regulation's implementation and compared case data with data from other states. The annual number of reported V. vulnificus infections and deaths in California with patient's sole exposure to raw oysters dropped from 0 to 6 cases and 0 to 5 deaths per year during 1991-2002, before implementation, to 0 during 2003-2010, after implementation (p = 0.0005 for both). In other states, median annual numbers of similar cases and deaths increased slightly after 2002. The data strongly suggest that the 2003 regulation led to a significant reduction in reported raw oyster-associated V. vulnificus illnesses and deaths.

Coccidioidomycosis-associated Hospitalizations, California, USA, 2000–2011

In the past decade, state-specific increases in the number of reported cases of coccidioidomycosis have been observed in areas of California and Arizona where the disease is endemic. Although most coccidioidomycosis is asymptomatic or mild, infection can lead to severe pulmonary or disseminated disease requiring hospitalization and costly disease management. To determine the epidemiology of cases and toll of coccidioidomycosis-associated hospitalizations in California, we reviewed hospital discharge data for 2000–2011. During this period, there were 25,217 coccidioidomycosis-associated hospitalizations for 15,747 patients and >$2 billion US in total hospital charges. Annual initial hospitalization rates increased from 2.3 initial hospitalizations/100,000 population in 2000 to 5.0 initial hospitalizations/100,000 population in 2011. During this period, initial hospitalization rates were higher for men than women, African Americans and Hispanics than Whites, and older persons than younger persons. In California, the increasing health- and cost-related effects of coccidioidomycosis-associated hospitalizations are a major public health challenge.

The public health impact of coccidioidomycosis in Arizona and California

The numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.

Impact of ASC-H terminology on the detection of HSILs in medically underserved California women

In this study we evaluated CDP: EWC, a large public health screening program for low-income women to determine whether the ASC-H term, introduced in the 2001 revision to the Bethesda System, has facilitated the detection of the most serious precancerous cervical lesions such as CIN-II-III/CIS, including accuracy of detection and minimizing diagnostic delays. Pap test and biopsy data from the period 2003-2006 were compared with those from 1995-1999, and included analysis of a subset of rarely and never-screened for each study period. More ASC-H Pap tests were followed by CIN-II+ biopsies (20%) than ASCUS Pap tests (5%). Thirteen percent of ASC-H showed CIN-III/CIS on follow-up biopsy. Following the introduction of ASC-H, negative and LSIL Pap tests followed by CIN-III/CIS biopsies decreased from 5.6% to 0.37% and 9.2% to 4.4%, respectively. Fewer CIN-III/CIS cases were preceded by Pap tests with negative and ASCUS results in 2003-2005 as compared with 1995-1999. The number of days from screening to diagnosis for women aged 25-39 years with ASC-H Pap test results (58 days) was less than for ASCUS results (78 days) for the current study period. In this high-risk multi-ethnic population, ASC-H more effectively communicates equivocal findings likely to represent HSIL leading to more rapid follow-up. The incidence of CIN-II or CIN-III/CIS following ASC-H Pap tests is lower than generally appreciated for this population, including for rarely or never-screened high-risk women. Fewer CIN-III/CIS lesions were detected following negative and ASCUS Pap results. Compliance with follow-up is less than ideal for this population.

Cervical cancer screening in medically underserved California Latina and non-Latina women: effect of age and regularity of Pap testing

BACKGROUND

This study focuses on age, race/ethnicity and regular cervical cancer screening of medically underserved Latina and non-Latina women enrolled in California's Cancer Detection Programs: Every Woman Counts (CDP: EWC).

METHODS

Data from a cohort of women were evaluated for regularity of screening and ethnicity utilizing multi-category logistic regression models to investigate Pap test and biopsy results.

RESULTS

There was no statistically significant difference among medically underserved Latina or non-Latina women in Pap test result and stage of cervical cancer after controlling for age and screening regularity. Rarely/never Pap-tested women were more likely to have 'SIL/ASC' (odds ratio=1.19; 95% confidence interval=1.08, 1.31) compared to women who were screened regularly. Medically underserved 25-39-year-old women were also more likely to be identified with 'SIL/ASC' (odds ratio=1.64; 95% confidence interval=1.50, 1.79) than women 50 and over. Younger were more likely to have low-grade 'HPV/Condylomata, Atypia/CINI/LSIL' (odds ratio=2.48; 95% confidence interval=1.66, 3.72) and high-grade 'CIN II/III/HSIL/CI/Other Cancers' (odds ratio=1.53; 95% confidence interval=1.08, 2.16) than women age 40 and above, similar to rarely/never Pap-tested women.

CONCLUSIONS

Women were more likely to be identified with high-grade precancerous cervical lesions and cancer process when they did not have regular screening, Ethnic differences in screening outcomes seem to be minimized by participation in a program that provides consistent screening resources to the medically underserved women who enroll. These findings support prevention strategies that expand screening to all medically underserved younger women or that provide HPV vaccination at an early age.

Applying the small-area estimation method to estimate a population eligible for breast cancer detection services

INTRODUCTION

Populations eligible for public health programs are often narrowly defined and, therefore, difficult to describe quantitatively, particularly at the local level, because of lack of data. This information, however, is vital for program planning and evaluation. We demonstrate the application of a statistical method using multiple sources of data to generate county estimates of women eligible for free breast cancer screening and diagnostic services through California's Cancer Detection Programs: Every Woman Counts.

METHODS

We used the small-area estimation method to determine the proportion of eligible women by county and racial/ethnic group. To do so, we included individual and community data in a generalized, linear, mixed-effect model.

RESULTS

Our method yielded widely varied estimated proportions of service-eligible women at the county level. In all counties, the estimated proportion of eligible women was higher for Hispanics than for whites, blacks, Asian/Pacific Islanders, or American Indian/Alaska Natives. Across counties, the estimated proportions of eligible Hispanic women varied more than did those of women of other races.

CONCLUSION

The small-area estimation method is a powerful tool for approximating narrowly defined eligible or target populations that are not represented fully in any one data source. The variability and reliability of the estimates are measurable and meaningful. Public health programs can use this method to estimate the size of local populations eligible for, or in need of, preventive health services and interventions.

Improving Rescreening In Community Clinics: Does A System Approach Work?

Community clinics provide inadequate breast cancer screening services to low-income, racially- and ethnically-diverse communities. This study develops and evaluates the effectiveness of multifaceted organizational system interventions--operational assessments, tracking systems, reminder calls, tailored education, physician prompts and a tailored counseling call--on mammography rescreening rates within three community clinics. We used the Chronic Care Model and Put Prevention Into Practice framework to redesign breast screening delivery services within the California Cancer Detection Programs: Every Woman Counts (CDP:EWC), community clinic settings. We used a quasi-experimental design with a random selection of 400 patients at pre-intervention. To establish a post-intervention clinic's rescreening rate a new comparable cross-sectional random sample of 347 women was drawn. Measures A chart abstraction instrument was used to establish clinics' rescreening rates. Subjects participants at pre and post-intervention were low-income women 50 years of age and older who had received normal mammography results and had not been diagnosed with breast cancer in the last five years. General linear mixed model analysis revealed significant improvements for the organizational system redesign condition [pre-intervention rescreening rate: 32.1 percent v. post-intervention rescreening rate 50.2 percent, (p < .001)]. For the organizational system redesign plus tailored counseling call condition, there was maintenance in the rescreening rate following the intervention [pre-intervention: 44.4 percent v. post-intervention: 45.1 percent, (p > 0.05)]. Multilevel interventions directed at redesigning community clinics primary care breast cancer screening services, can improve mammography rescreening rates.

Stage of Breast Cancer Diagnosis Among Medically Underserved Women in California Receiving Mammography Through a State Screening Program

OBJECTIVE

This study describes breast cancer stage at diagnosis among California women receiving mammograms through a state-administered screening program in comparison to other California women.

METHOD

Linked data from California-administered screening programs and the California Cancer Registry were used to identify participants diagnosed with breast cancer between 1994 and 2000. Logistic regression was used to compare the adjusted likelihood of late stage disease among program participants (categorized into four subgroups based on the timing and frequency of mammograms) to non-participants in California diagnosed during the same time period.

RESULTS

Program participants were significantly more likely than non-participants to be diagnosed at late stage (adjusted OR 1.2; 95% CI 1.1, 1.3), with the highest risk occurring among those diagnosed 0-1 months after initial mammogram (adjusted OR 1.8; 95% CI 1.6, 2.1). The stage distribution among regularly screened participants was similar to non-participants (adjusted OR of late stage disease 0.9; 95% CI 0.7, 1.1).

CONCLUSIONS

Although program participants were more likely to be diagnosed at late stage than non-participants, their stage distribution was distinctly different according to their pattern of mammography utilization. This likely reflects differential utilization of program diagnostic and screening services, which should be taken into account in program evaluation.

Patient and Clinical Site Factors Associated With Rescreening Behavior Among Older Multiethnic, Low-Income Women

PURPOSE

Our goal was to identify factors predictive of mammography rescreening within 18 months of baseline screening in multiethnic, low-income older women.

DESIGN AND METHODS

We interviewed a cross-sectional survey of staff of 102 randomly selected clinics that provided screening and diagnostic services. We also surveyed a random sample of 391 older women served by these clinics to retrospectively assess their experiences of the screening process.

RESULTS

We found that 59% of the sample returned for a repeat mammogram. Education level and the belief it is important to get an annual mammogram were significant patient-level predictors of rescreening. Offering pap smears and using hands-on demonstrations with breast models were significant clinic-level variables predictive of rescreening. Of note, among the variables that did not prove significant in the final model were those reflecting ethnicity and income.

IMPLICATIONS

Individual and health-care-delivery-system factors play important roles in the obtaining of regular mammograms by low-income women. These findings highlight the importance of both factors in improving rescreening rates among older women.

Role of Pap Test terminology and age in the detection of carcinoma invasive and carcinoma in situ in medically underserved California women

Our goals were to evaluate Pap Test findings classified by the Bethesda system, and follow up biopsies from participants in the California Breast and Cervical Cancer Control Program (Ca-BCCCP) for: 1) correlation in the detection of carcinoma in situ (CIS) and carcinoma invasive (CI), and 2) age-related trends, with discussion in the context of the 2001 ASCCP Management Guidelines. Women (n = 52,339) who had their initial screening Pap Tests with Ca-BCCCP between January 1995-December 1999 were followed for diagnostic services through December 2000. Descriptive and analytical methods were used in the analysis. Of the Pap results, 81.9% were negative, 10.6% showed infection, 4.7% showed an epithelial abnormality as defined by the Bethesda system (atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), or high-grade squamous intraepithelial lesion (HSIL)), 0.1% showed squamous-cell cancer (SCC), and 2.7% showed other or unsatisfactory. Subsequent to the initial Pap Test, follow-up results of carcinoma in situ (CIS) and carcinoma invasive (CI) accounted for 0.36% and 0.05% of the population, respectively. Among HSIL Pap Tests (n = 285), 40.7% had follow-up showing CIS. Among SCC Pap Tests, 17.9% had follow-up results of CIS and 28.6% CI. Of the 191 patients with CIS as a follow-up finding, the initial Pap smear showed: HSIL 60.7%, SCC 2.6%, LSIL 10.5%, ASCUS 13.6%, and negative or infection 9.9%. Of the 27 patients with CI, the initial Pap Test showed: HSIL 40.7%, SCC 29.6%, LSIL 7.4%, ASCUS 7.4%, and negative or infection 11.1%. Pap diagnoses of other or unsatisfactory accounted for 2.6% of the Pap results from patients with CIS and 3.7% of Pap results from patients with CI. Except for LSIL, there was an increasing age trend in the number of cases in each of Pap results, with the exception of age 65+ yr. However, the ratio of LSIL and ASCUS to negative cases decreased with age. (P < 0.0001 and 0.0293, respectively). HSIL Pap results indicate a reasonably high probability of CIS and CI. However, approximately 1/3 of patients with CIS and 1/4 of patients with CI presented with Pap diagnoses of less severity than HSIL. When a negative Pap Test result is chosen as reference group, there is a negative age trend for LSIL and ASCUS, and no age trend for other results. These findings all have important implications in the design of follow-up strategies, and support the 2001 ASCCP Consensus Guidelines for the Management of Women with Cervical Abnormalities.

Mammography Rescreening Among Women of Diverse Ethnicities: Patient, Provider, and Health Care System Factors

This study identified patient, provider, and health care system factors that influenced mammography rescreening among non-insured, racial/ethnic minority women. Data were collected using a stratified-clustered random sample survey of 1,050 women of five racial/ethnic groups (Latina, Chinese, Filipina, African American, and Caucasian) and 102 primary care clinical sites. Women received screening services through two no-cost screening programs in California. Chi-square tests were used to assess bivariate associations and multiple logistic regressions were used to compute adjusted odds ratios and 95% confidence intervals. Mammography rescreening was associated with living in the United States longer; having higher education levels, better health care access, a history of breast problems, and favorable perceptions of mammography; obtaining regular Pap screening and hormone replacement therapy; having had better communication with clinicians; and attending clinics that conducted in-reach activities. This study suggests that simply removing financial barriers is not enough to improve mammography rescreening among underserved women.

Race/ethnicity and other risk of factors associated with cryptosporidiosis as an initial AIDS-defining condition in California, 1980-99

To study whether African-Americans are less likely than whites to present with cryptosporidiosis as an AIDS-defining condition (ADC), a case-control study was conducted using a large, population-based surveillance registry of AIDS patients in California. Data from January 1980 through June 1999 were analysed using risk factor stratification and multivariate logistic regression to evaluate confounding by other risk factors such as gender, injection drug use (IDU), CD4 counts, age and sexual orientation. Cases included 1373 subjects with cryptosporidiosis as an ADC and controls included 97,419 subjects with other ADC. The results indicate a significantly lower risk for presentation with cryptosporidiosis as an ADC among African-Americans compared with whites (OR vs. whites = 0.5, 95% CI 0.4, 0.7). Additionally, there is evidence that heterosexuals are less likely than homosexual/bisexual males to present with cryptosporidiosis (OR = 0.5, 95% CI 0.4, 0.7). Our analyses also suggest a decreasing risk with increasing age. The possibility that there may be biologic factors or differential lifetime exposures that account for the difference between the racial/ethnic groups merits further investigation.

A change-point model for reporting delays under change of AIDS case definition

Accurate monitoring of disease incidence is of major public health concern. The time delay between diagnosis and the date of reporting creates bias in estimating disease incidence. Changes in case definition are expected to have an impact on the time lag of case reporting. We propose a change-point model for reporting delays in AIDS that takes into account recent changes in the AIDS definition in US and European countries. The model was applied to California AIDS surveillance data and the distribution of reporting delays before and after the recent change of definition in 1993 were analyzed in terms of contributing factors. The overall significance of the model with change-point as compared to the model without change-point indicates that the effect of the 1993 change in definition on the distribution of reporting delays was highly significant (p < 0.0001). Overall, reporting delay of cases initially diagnosed with AIDS-defining diseases before 1993 was shorter compared to after 1993; reporting delay of cases initially diagnosed meeting the 1993 immunologic case definition was shorter than of those initially diagnosed with AIDS-defining diseases. Region of residence, mode of exposure, race/ethnicity and time of diagnosis emerged as the main covariates in the models. The method introduced here applies to current and possible future changes of the AIDS case definition as well as changes in diagnostic criteria or case definition in diseases other than AIDS. We demonstrate that such changes may be accompanied by sizeable changes in the distribution of reporting delays, and thus adjustment for reporting delays must be recalibrated after a change in definition.

Temporal trends and factors associated with survival after Pneumocystis carinii pneumonia in California, 1983-1992

The authors investigated quarterly trends in survival after the diagnosis of Pneumocystis carinii pneumonia for 19,607 patients in California in the decade from January 1, 1983, through December 31, 1992. Subjects included all cases for whom P. carinii pneumonia was the initial (and only) acquired immunodeficiency syndrome (AIDS)-defining diagnosis as reported to the California human immunodeficiency virus/AIDS surveillance registry. There was a period of rapidly improving survival from approximately June 1986 until April 1988, coincident with the widespread introduction of antiretroviral therapy (zidovudine) and the institution of P. carinii pneumonia prophylaxis (with cotrimoxazole and pentamidine). There was no evidence, however, of meaningful improvements in survival for these patients after that period. The association of several covariates (risk transmission group, gender, race/ethnicity, certainty of P. carinii pneumonia diagnosis, age, region of residence, availability of CD4 count, and level of CD4 count) were also studied both by proportional hazards regression and by recursive partitioning (i.e., tree-based) survival analysis. The availability of a CD4 count (regardless of its level) was the single factor most strongly associated with survival (median survival 36 months among those with and 14 months among those without reported CD4 counts, p < 0.05). Data from this large, population-based surveillance registry of AIDS in California suggest that, despite earlier improvements in survival after the diagnosis of P. carinii pneumonia, the long-term survival of these patients remains poor (39% alive 2 years after diagnosis) and that no improvement in survival has occurred since 1988.

Human immunodeficiency virus disease in California. Effects of the 1993 expanded case definition of the acquired immunodeficiency syndrome

On January 1, 1993, the case definition of the acquired immunodeficiency syndrome (AIDS) in adults and adolescents used for monitoring the AIDS epidemic in California was expanded to include persons infected with the human immunodeficiency virus (HIV) with CD4 T-lymphocyte counts of less than 200 x 10(6) per liter (< 200 per mm3), pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer. To assess the implications of this revision on AIDS case reporting in California, we compared cases reported through the end of 1994 based on 1 or more of the 4 new AIDS-defining conditions added in 1993 to cases reported based on pre-1993 AIDS-defining opportunistic infections and cancers. The 4 new conditions included in the 1993 expanded AIDS case definition accounted for a 23% increase in cumulative AIDS cases reported in California by the end of 1993, a 170% increase in the number of cases reported during 1993, and an 88% increase in the number of patients with AIDS living at the end of 1993. The number of cases reported in 1993 (19,629) was 124% more than that reported in 1992 (8,780) and 69% more than that reported in 1994 (11,587). The proportion of cases among women, injection-drug users, and African Americans also increased as a result of this change in the case definition. The expansion of the case definition may have resulted in a peak or plateau in the AIDS incidence in California because of reporting earlier in the HIV disease progression. The expanded case definition has enhanced the usefulness of AIDS surveillance data for targeting secondary prevention efforts, but more behavioral and HIV serosurveys are still needed to adequately target primary HIV prevention efforts.

Timely reporting of AIDS cases

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